Download Canada at the Tipping Point

DIABETES:
CANADA AT THE
TIPPING POINT
Charting a new path
Policy Backgrounder
Issue: Canada is at a tipping point and here are the reasons why...
• The total population with diabetes in Canada is estimated to be 3.1 million
people (8.6%) in 2013, and will rise to 4.2 million people (10.8%) by 2020. An
additional almost one million have the disease but do not know it. Over
one in four Canadians lives with diabetes or prediabetes; this will rise to one in
three by 2020 if trends continue.
• Diabetes also cost our healthcare system and economy $13.1 billion in 2013
and is projected to cost $16 billion annually by 2020. Unless we take action,
diabetes threatens not only more Canadians, but also our healthcare system
and prosperity.
• Affordability and access to diabetes medications, devices and supplies vary
depending on where you live in Canada. While some jurisdictions have
increased support, costs continue to be a barrier for many with diabetes.
• Atlantic Canada has the greatest burden, but provinces with the lowest
prevalence rates have the highest rates of prevalence growth. Aboriginal
peoples, immigrants, some ethnocultural communities, low-income Canadians
and women within these populations bear a heavier burden
of the disease. While best practices in diabetes programs and services exist
across Canada, information about them is lacking.
• For diabetes prevalence, hospitalizations, mortality and access to medications,
Canada performs poorly.
Diabetes: Canada at the Tipping Point – Charting a New Path | Policy Backgrounder
Canada has a choice to make to “tip” the course of diabetes.
We can continue on our current trajectory and achieve similar
results, or chart a new path to provide hope to Canadians
with diabetes or prediabetes. While the Canadian Diabetes
Association’s report entitled Diabetes: Canada at the Tipping
Point – Charting a New Path indicates that some progress has
been made by governments to address diabetes over the past
several years, it is dwarfed by the growing burden of this
disease across Canada. To avoid falling further behind, we
must take immediate action to chart a new path to respond to
diabetes in Canada.
To move forward, federal, provincial and territorial
governments must use whatever suitable methods are
available to them to work in collaboration with stakeholders
and partners. To meet the challenge of diabetes in Canada,
governments must:
• Reassess and refocus their strategic approach to diabetes
to achieve the greatest gains in addressing the burden of
diabetes, including costly and potentially life-threatening
complications from the disease.
• Ensure that all people living with diabetes have
comparable access to the supports they need to effectively
self-manage their disease in collaboration with their
healthcare providers; and
• Enhance and refocus their investments in addressing
the burden of diabetes into programs and services that
provide the greatest support to those people living with
the disease.
To tip the course of diabetes in Canada, the Canadian
Diabetes Association (CDA) and Diabète Québec (DQ)
recommend that governments collaborate with partners to:
1. Reduce the burden of diabetes, including:
a. Implementing a comprehensive Pan-Canadian healthy weights strategy
b. Instituting a comprehensive secondary prevention strategy
c. Implementing a national knowledge dissemination
platform for diabetes
2. Enhance access to quality care and support for
people living with diabetes, including:
d. Standardizing the quality of diabetes education across Canada
e. Renewing the vision for the Canadian drug approval process
f. Creating a Canadian diabetes health charter
3. Strategically invest in diabetes, including:
g. Enhancing financial assistance for people living with
diabetes
h. Enhancing the Canadian Diabetes Strategy (CDS) and
Aboriginal Diabetes Initiative (ADI)
i. Increasing investment in high quality, pan-Canadian
research
Pan-Canadian healthy weights strategy
Sixty-one per cent of Canadians are overweight or obese.1
The rising rate of excess weight in Canada is a significant risk
factor in increasing diabetes prevalence. Obese persons have
the highest individual diabetes risk (27.4%), but those who
are overweight have the greatest population risk (9.9%) of
developing the disease since, despite their lower individual risk,
there are more overweight people compared to those who are
obese (7 to 1).2 To achieve maximum benefit for all Canadians
in diabetes management and prevention, governments need to
expand their focus to include Canadians who are overweight as
well as obese.
Maintaining a healthy weight is essential to preventing diabetes,
including for those with prediabetes3, and also delaying or
avoiding altogether the secondary complications of diabetes.
Although there is a genetic predisposition for diabetes, even
a modest weight reduction (5-10% of total body weight) can
reduce the chance of developing or at least delaying type 2
diabetes by over 50%.4 Therefore, for the millions of Canadians
with diabetes or prediabetes, maintaining a healthy weight is one
of the most important elements in managing their disease.
The Canadian Diabetes Cost Model (DCM)5 shows that a
2% reduction in new cases of diabetes would result in a 9%
reduction in the direct cost of diabetes to the healthcare system,6 thus allowing the direction of limited healthcare resources
toward meeting the needs of all Canadians. Furthermore, a
recent study in Ontario showed that new cases of diabetes could
be reduced by 10% in that province between 2007 and 2017 by
reducing the average BMI for all Ontarians by 3.3%.7
Achieving healthy weights within our population will mean a
significant shift in the approaches by governments, private sector
involvement and, most of all, a widespread personal and societal
change. A Pan-Canadian Healthy Weights Strategy would seek
to increase the percentage of Canadians maintaining a healthy
weight and thereby reduce diabetes prevalence rates and the
complications associated with diabetes. The strategy must focus on four major goals:
1. Identifying and understanding the underlying societal causes
of obesity and unhealthy weights.
2. Setting targets to increase the number of Canadians achieving
healthy weights, specifically within “at-risk” populations (e.g.
2
Diabetes: Canada at the Tipping Point – Charting a New Path | Policy Backgrounder
children, those with prediabetes or diabetes).
3. Creating the appropriate “public environment” for the
population to achieve healthy weights through a multidimensional and multi-sectoral approach.
4. Improving access to healthy weights programs and
services for high-risk populations.
Comprehensive secondary
prevention strategy
One of the most significant factors driving the rise in diabetes
in Canada is the demographic composition of jurisdictions
across the country. This poses a difficult challenge since
despite all efforts made by governments to reduce diabetes,
Canada is partially “locked-in” to increasing diabetes
prevalence over the next decade.
Government needs to ensure that Canada is prepared for
increasing diabetes prevalence, so that our healthcare system
can absorb this burden. While a certain percentage of this
increase is locked in, the impact of diabetes can be mitigated.
For example: • Effective treatment exists for diabetes. When managed
correctly by a healthcare team, people living with diabetes
can lead healthy and productive lives.
• Effective treatment of diabetes saves governments money.
The DCM indicates that 80% of all diabetes costs come
from the complications associated with the disease, and
not the treatment of the disease itself. So, even a small
gain in the prevention or delay of secondary complications
can provide huge savings.
To address increasing diabetes prevalence, the Association
recommends that all governments include within their
approach to diabetes a broad-based secondary prevention
strategy to exclusively target people who have been
diagnosed with diabetes or prediabetes. This strategy
should provide them with the tools, support and services
to effectively self-manage their disease and prevent or
delay secondary complications, including a comprehensive
diabetes risk assessment model for screening, and culturally
specific educational and nutrition tools to support lifestyle
modification counselling.
National knowledge dissemination
platform
Diabetes: Canada at the Tipping Point – Charting a New Path
provides examples of best practices for diabetes services,
care and education across Canada. However, accessible
information about these supports is lacking and not shared
between jurisdictions, resulting in the duplication of work and
lost opportunities for collaboration and learning. In fact, the 2009
Report by the Expert Panel of the Diabetes Policy Review noted that
“work to support knowledge exchange in the area of diabetes has
been very limited to date.”8 The Canadian Diabetes Association
echoes the Expert Panel’s recommendation for a national platform
for knowledge dissemination and exchange to enable jurisdictions
and healthcare providers to learn from each other to provide
optimal care and support for people with diabetes.
Standardize the quality of diabetes
education across Canada
Diabetes self-management education is associated with important
health benefits for people with diabetes, including reductions
in A1C and improved quality of life.9 Accordingly, all Canadians
with diabetes regardless of where they live in Canada need
access to high-quality diabetes education to ensure optimal selfmanagement to delay or avoid secondary complications.
While several jurisdictions have innovative diabetes education
programs, most do not require their diabetes education centres
(DECs) to comply with DES/CDA’s Standards for Diabetes
Education. All jurisdictions should recognize these standards as
the model for diabetes education in Canada, require their DECs
to undergo regular evaluation, and promote their best practices in
care and programs across jurisdictions. In addition, to ensure all
Canadians with diabetes receive high-quality diabetes education,
certification programs accessible to all healthcare professionals are
needed.
Renew the vision for the Canadian
drug approval process
Health Canada determines the safety of all medications and
approves them for use. Before gaining market authorization,
manufacturers must present scientific evidence of their product’s
safety, efficacy and quality as required by the Food and Drugs
Act and Regulations. Then, each jurisdiction across Canada
determines if the medication should be included in its formulary
of medications and medical supplies covered by its drug plan. A product may be available to everyone who is eligible (“listed”);
only available under special circumstances (“restricted”); or not
available (“not listed”).
The practice of new diabetes medications approved by
Health Canada being classified as “restricted” or “not listed”
in formularies means that these effective treatments are not
available to some Canadians, potentially compromising their selfmanagement. Only those with private drug plans or their own
resources can acquire these therapies, meaning two-tiered access
to these supports. Diabetes: Canada at the Tipping Point – Charting
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Diabetes: Canada at the Tipping Point – Charting a New Path | Policy Backgrounder
a New Path indicates that access to many diabetes medications
remains inconsistent across jurisdictions. In 2009, Canada
reimbursed fewer drugs than the OECD average and we
ranked near the bottom in reimbursement for the latest
treatments for diabetes.
Clearly, the current drug review process results in too many
Canadians not having equitable access to the medications,
devices and supplies required for effective self-management.
Canada must do better. To this end, in 2012, the Association
released a report entitled In the Balance: A Renewed Vision
for the Common Drug Review which includes a review of best
practices internationally to identify a more effective and
efficient drug review system that better serves the health
needs of all Canadians. Key stakeholders were engaged in a
subsequent summit attended by public drug programs, policy
makers, researchers, patient groups, healthcare professionals
and industry. As informed by the key stakeholders, the
Association will advocate for a pan-Canadian approach to:
1. Clarify all aspects of the drug review process, including
the roles and responsibilities of the CDR and participating
drug plans.
2. Meaningfully capture patient and societal values to ensure
that patient experience is optimally represented.
3. Strengthen transparency to ensure that governments, the
CDR, and manufacturers are held accountable to disclose
assessment criteria, evidence, and rationale for decisions.
Jurisdictions should also explore a common drug formulary
to standardize access.
Create a Canadian diabetes health charter
As noted above, major findings of Diabetes: Canada at the
Tipping Point – Charting a New Path include:
• Where you live in Canada greatly affects your ability to
effectively manage your diabetes.
• Difficulty exists in accurately assessing the progress
being made to address the increasing burden of diabetes
in Canada due to lack of accessible information across
jurisdictions concerning diabetes supports. To be able to assess progress in addressing diabetes, Canada
needs to have a transparent assessment tool to measure
progress across jurisdictions. Such a tool would assess the
quality and accessibility of diabetes care, programs and
services, medications, education and other supports. These
standards will enable us to assess the performance of all
jurisdictions against a common set of benchmarks developed
by experts in diabetes care, management and education.
Enhance financial assistance for people with
diabetes
Affordability and access to diabetes medications, devices and
supplies remain the greatest challenge for Canadians with
diabetes, many of whom face a significant health and financial
burden. Healthcare costs for Canadians with diabetes not covered
by either public or private insurance plans can be two to five
times higher than for people without diabetes, including expenses
for:
• Supplies such as syringes, glucose testing meters, test strips
and insulin pumps.
• Insulin and/or other diabetes drugs and therapeutics.
• Other medication to lower cholesterol, blood pressure, etc.
• Frequent medical visits and diagnostic tests.
• Specialized home care visits, and rehabilitation or permanent
residential care should debilitating complications arise.
People with diabetes face these costs in almost all parts of
Canada. The average annual out-of-pocket cost for a person
with type 2 diabetes is just under $2,300. These costs often
compromise the ability of Canadians with diabetes to manage
their disease: 57% do not comply with their prescribed medical
therapy due to these costs. If Canadians with diabetes could
afford to manage their disease more effectively and avoid or delay
serious complications, it would improve their quality or life and
reduce the cost burden of diabetes. Accordingly, the government
of Canada should institute a system of enhanced tax credits to
enable people with diabetes to be eligible for a non-refundable
tax credit or a refundable payout to lower medical and treatment
costs. This would reduce the financial burden of supplies and
medications needed to manage diabetes.
Enhance the Canadian Diabetes Strategy and
Aboriginal Diabetes Initiative
In 1999, the Government of Canada pledged $115 million over
five years to the CDS to enable Canadians to benefit more fully
from the considerable resources and expertise available across
the country concerning this disease. Partners in the CDS include
the provinces and territories, various national health bodies and
interest groups, and Aboriginal communities across the country.
The CDS supports:
• The National Diabetes Surveillance System (NDSS), which
provides surveillance information concerning diabetes at
provincial, territorial and national levels.
• Knowledge development and exchange for diabetes prevention
and management, which supports research and evidence to
provide the basis for understanding the causes of diabetes, as well as its prevention, effective management and cure.
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Diabetes: Canada at the Tipping Point – Charting a New Path | Policy Backgrounder
• Diabetes community-based promotion and programming,
which promote a positive shift in health status in high-risk
populations.
In 2005, the federal government extended funding for the
CDS within the larger envelope of the integrated Strategy on
Healthy Living and Chronic Disease, increasing funding to
$18 million a year from $15 million.
Established in 1999, the Aboriginal Diabetes Initiative (ADI)
had initial funding of $58 million over five years. It was then
expanded in 2005 with a budget of $190 million over five
years. Budget 2010 included a commitment of $110 million
over two years for the ADI. Currently, Health Canada is
investing over $50 million per year to support the third phase
(2010-2015). The ADI supports more than 600 programs for
Canadian Aboriginals living with diabetes.
Given the doubling of prevalence rates for diabetes, we urge
the federal government to augment funding for diabetes
accordingly on an annualized basis by doubling the current
annual allotment to the CDS of $18 million to $36 million. In addition, to ensure stable and reliable funding for the
ADI, we urge the federal government to commit permanent
funding for the ADI at current levels beyond 2015, with
annual increases in the years after 2015 appropriate to
address population increases within these constituencies.
Increase investment in high-quality
research
for basic research in recent budgets. Adjusted for inflation,
Canada’s three granting councils (CIHR, NSERC, and SSHRC)
saw steady erosion in their base budgets, even with the recent
increases. Between 2007-08 and 2011-12, funding for CIHR,
NSERC and SSHRC declined by 4.1%, 1.2% and over 10%
respectively.10 11 Without increased investments in research,
Canada may lose its competitive edge that previous investments
in research have achieved.
The Canadian Association of University Teachers recommended
increasing basic research funding for Canada’s three granting
councils by $500 million a year. 12 It is important to note that this
increase would benefit research activity in many different sectors
and areas of interest and importance to Canadians, and assist in
Canada’s productivity and competitiveness.
It is also important to point out that 84% of Canadians
indicate investing in high-quality research makes an important
contribution to the economy. Furthermore, 90% think basic
research should be supported by government even if it brings no
immediate benefit, and a majority of Canadians are willing to pay
more to improve health and research capacity even in uncertain
economic times.13
Canada is not keeping pace with its peer countries for investment
in diabetes research, given funding reductions to our three
granting councils in recent budgets and limited reinvestments.
Canada needs to increase its commitment to research to build on
the accomplishments that previous investments in research have
achieved.
The federal government has not committed adequate support
Notes
Statistics Canada. Canadian Health Measures Survey, 2009-2011. September 2012. Available at: http://www.statcan.gc.ca/pub/82-625-x/2012001/article/11708-eng.pdf
According to this survey, approximately 32% of Canadian men were at a healthy weight. About 1% were underweight, 40% were overweight and 27% were obese. For
women, 44% had a healthy weight, while 29% were overweight, 25% were obese and 3% were underweight.
2 Institute for Clinical Evaluative Science. How Many Canadians Will Be Diagnosed with Diabetes Between 2007 and 2017? 2010.
3 Prediabetes exists when blood glucose is elevated, but not as high as type 2 diabetes.
4 See the Canadian Diabetes Association. An economic tsunami: the cost of diabetes in Canada, 2009, p. 15.
5 The Diabetes Cost Model integrates incidence estimates and administrative prevalence from the Canadian NDSS and economic cost estimates from The Economic
Burden of Illness in Canada to estimate and forecast diabetes prevalence and cost. It supports analysis of sensitivity in prevalence and cost in response to demographic
data, incidence and mortality rates by age (from age 1+) and sex, and the average annual number of net general practitioner and specialist visits by people with diabetes.
Additional information concerning details of the DCM are available at: http://www.diabetes.ca/economicreport/.
6 See An Economic Tsunami, p. 16.
7 See How Many Canadians Will Be Diagnosed with Diabetes Between 2007 and 2017? 2010.
8 The Report of the Expert Panel for the Diabetes Policy Review is available in its entirety on the website of the PHAC at: www.phacaspc.gc.ca/publicat/2009/dprrep-epdrge/
index-eng.php.
9 CDA. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Canadian Journal of Diabetes 37(2013): S26-S27.
Reductions in A1C have been shown in persons with type 2 diabetes, whereas improved quality of life has been shown in persons with either type 1 or type 2 diabetes.
10 The Canadian Association of University Teachers. Statement Regarding the 2012 Federal Budget, pp. 1-2.
11 The 2009 Federal Budget reduced funding to the granting councils by $149.0 million over three years, followed by a slight increase of only $32 million in Budget 2010.
Budget 2011 added a modest increase of $37 million, with an additional $10 million allocated to the Indirect Costs Program administered by SSHRC. Budget 2012 contained
no increase in the budgets of the three granting councils; rather, the government planned to cut $37 million and “reinvested” it in academic-industry partnerships. Budget
2013 brought no net increase in the budgets, as the “increase” of $37 million matches the planned cut of the same amount announced in the previous year.
12 See note 11.
13 The Association of Faculties of Medicine of Canada, BIOTechCanada, Rx&D, Canadian Healthcare Association, MEDEC, Research Canada: An Alliance for health Discovery.
Canada Speaks! 2010: Canadians Go for Gold in Health and Medical Research - A National Public Opinion Poll in Health and Medical Research, January 2010, p. 5.
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